A nurse is caring for a client who is 3 days postoperative following open heart surgery and will be transferred to the medical-surgical unit. Which of the following information should the nurse plan to include in the verbal report?
The client's dressing change schedule.
The client's level of consciousness.
The client's vital signs from the previous shift.
The client's occupation.
The Correct Answer is B
Choice A rationale:
The nurse should not include the client's dressing change schedule in the verbal report when transferring care to the medical-surgical unit. While this information is important for the client's care, it is not a priority for the receiving unit to know during the immediate transfer. Dressing change schedules can vary based on the type of surgery and wound healing progress, and the medical-surgical unit will focus on the client's overall condition.
Choice B rationale:
The client's level of consciousness is a critical piece of information to include in the verbal report when transferring care. Changes in level of consciousness can indicate neurological deterioration or potential complications, especially after a major surgery like open heart surgery. This information helps the receiving nurses monitor the client's condition closely and respond appropriately if any deterioration occurs.
Choice C rationale:
While reporting the client's vital signs from the previous shift is important, it might not be the most relevant information during the immediate transfer from the postoperative unit to the medical-surgical unit. Vital signs can change rapidly, and the receiving nurses will assess the client's current vital signs upon arrival. Therefore, this information is not the priority for the verbal report.
Choice D rationale:
The client's occupation is not a critical piece of information to include in the verbal report during a transfer from the postoperative unit to the medical-surgical unit. The primary focus of the transfer report should be on the client's immediate postoperative condition, potential complications, and any other information directly related to their current medical status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
The nurse's first priority in the event of a fire is the safety and well-being of the clients. Clients who are in immediate danger due to the fire should be assisted to a safe location as quickly as possible. This choice is supported by the principles of prioritizing client safety during emergencies.
Choice B rationale:
Closing doors and windows on the unit is a secondary action and comes after ensuring the safety of clients in immediate danger. While it can help contain the fire's spread, it should not be the nurse's first action, as it does not address the immediate risk to clients' lives.
Choice C rationale:
Attempting to extinguish the fire using an ABC fire extinguisher might be a consideration in emergency situations; however, the nurse's first responsibility is to ensure the safety of clients. The nurse should not put themselves or clients at risk by attempting to extinguish the fire before moving clients to safety.
Choice D rationale:
Discontinuing oxygen use for clients who can breathe without it is not the nurse's primary action during a fire emergency. While it's important to manage resources, such as oxygen, the immediate focus should be on evacuating clients from the danger zone.
Correct Answer is B
Explanation
Choice A rationale:
A client who is scheduled for a tubal ligation in 2 hr and is crying. Rationale: While the emotional well-being of this client is important, the absence of pulse in the right foot of the client in choice B indicates a potentially critical vascular issue that requires immediate attention.
Choice B rationale:
A client who has peripheral vascular disease and has an absent pulse in the right foot. Rationale: The correct choice. An absent pulse in a client with peripheral vascular disease suggests compromised blood flow and potential tissue ischemia. This is a critical situation that requires urgent intervention to prevent further complications.
Choice C rationale:
A client who has type 1 diabetes mellitus and needs the first dressing change for an ulcer. Rationale: While dressing changes are important, they are not as time-sensitive as addressing compromised blood flow and potential tissue damage seen in choice B.
Choice D rationale:
A client who has methicillin-resistant Staphylococcus aureus (MRSA) and has an axillary temperature of 38°C (100.4°F). Rationale: Although an elevated temperature can be concerning, the absence of a pulse in a peripheral vascular disease client (choice B) takes precedence as it suggests a more immediate threat to the client's limb and overall health.
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